Are clear aligners really kinder to teen gums?
Using aligners to straighten teeth has become very popular among both adolescents and teenagers. Many prefer aligners for esthetics, comfort, and removability, while they also seem like a safer option than fixed appliances for oral hygiene, caries, and gingival health.
Fixed orthodontic treatment, braces, are notorious for increasing plaque accumulation, causing gingivitis, and heightening the risk of initial caries – especially in younger patients. Among adolescents with braces, the prevalence of gingivitis ranges from 35 to 50%, much higher than in adults, where it ranges from 20–25 %.1,2 Given the drawbacks of braces, many clinicians and parents assume that clear aligners are the solution. But are they, really?
A recent prospective observational study by Zhang et al.3 challenges this assumption and highlights an important clinical message: adolescents wearing clear aligners are still at significant risk of developing gingivitis, and even more so than adults.
What did the study look into?
The study investigated the incidence of gingivitis and changes in gingival health during clear aligner orthodontic treatment, comparing adolescents and adults over a six-month period.
A total of 120 patients undergoing clear aligner therapy were included:
- 66 adolescents (mean age ≈14.2 years)
- 54 adults (mean age ≈25.7 years)
Each age group was further divided into:
- A study group receiving personalized oral hygiene education
- A control group receiving routine periodontal care
All patients started treatment with healthy gingiva (GI = 0) following professional periodontal therapy. Gingival health was assessed regularly using the Gingival Index (GI), and the incidence of gingivitis was evaluated after six months.
Importantly, plaque visualisation using disclosing agents was incorporated during professional visits, allowing both clinicians and patients to see areas where plaque control could be better.
Important findings in the study
Several clinically significant findings emerged from the study. Here’s a selection:
Adolescents are highly susceptible to gingivitis during clear aligner treatment
Gingivitis developed in a substantial proportion of adolescent patients during treatment, confirming that clear aligners do not eliminate gingival risk in this age group. In this observational study, 39% of the adolescents developed gingivitis.
Gingival inflammation increased early in treatment for teens
Adolescents showed a rapid rise in GI scores, already noticeable at the 1.5 month follow up. This suggests that gingival problems may develop early and silently if not actively monitored.
Adults showed more stable gingival responses
In adults, changes in GI were smaller and less dependent on whether they received oral hygiene education or routine periodontal care. This could be the result of better compliance and oral hygiene habits in adult patients.
Education alone was not enough for adolescents
What might seem odd, is that adolescents who received oral hygiene education showed greater increases in GI than those receiving basic periodontal treatment alone. This highlights a key challenge: knowledge does not automatically translate into behaviour in teenagers.
Clear aligners are not risk-free
Attachments, aligner wear for >22 hours/day, and changes in the oral microenvironment can still promote plaque retention and gingival inflammation—particularly in adolescents with suboptimal hygiene routines.
Clinical relevance
This study sends a clear message to dental professionals: Clear aligners should not be considered a “gingivitis-safe” option for adolescents.
Teenagers differ fundamentally from adults in:
- Hormonal status (puberty-related gingival reactivity)
- Manual dexterity
- Motivation and compliance
- Dietary habits and snacking frequency
Even though aligners are removable, adolescents often:
- Brush fewer times per day
- Clean less effectively around attachments
- Reinsert aligners without adequate plaque removal
- Overestimate their own oral hygiene performance
Importance of plaque visualisation and check-ups
The use of disclosing agents in this study proved especially valuable. Visualising plaque accumulation makes oral hygiene failures tangible for adolescent patients and supports more meaningful, individualised instruction.
Equally important is the role of regular periodontal health check‑ups. Professional plaque removal and repeated reinforcement appear to be more effective than verbal instruction alone in reducing gingival inflammation in teens.
For clinicians, this means shifting the mindset from “aligners are easier to keep clean” to “aligners still require structured periodontal supervision - especially in adolescents.”
